a nurse is talking with another nurse on the unit and smells alcohol on her breath which of the following actions should the nurse take a nurse is talking with another nurse on the unit and smells alcohol on her breath which of the following actions should the nurse take
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ATI RN

ATI Fundamentals Proctored Exam

1. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take?

Correct answer: Confront the nurse about the suspected alcohol use.

Rationale: Confronting the nurse about the suspected alcohol use is the most appropriate action in this situation. It is essential to address the issue directly and express concerns about patient safety and potential impairment. By addressing the situation promptly, the nurse can potentially prevent harm and provide support to the colleague in need.

2. Terrance, whose birth mother drank heavily throughout pregnancy, has a thin upper lip, short eyelid openings, a small head, and a smooth philtrum. His physical growth has been slow, and he shows impairment in memory, attention span, motor coordination, and social skills. Terrance has __________.

Correct answer: A

Rationale: Terrance exhibits a combination of physical abnormalities like a thin upper lip, short eyelid openings, a small head, and a smooth philtrum, along with developmental delays and cognitive impairments. These characteristics are indicative of fetal alcohol syndrome (FAS), which is caused by maternal alcohol consumption during pregnancy. FAS is a severe condition resulting from prenatal alcohol exposure and is characterized by a range of physical, cognitive, and behavioral issues. Choice A, fetal alcohol syndrome, is the correct answer as it aligns with Terrance's symptoms and the effects of maternal alcohol consumption during pregnancy. Choices B, C, and D are incorrect because they do not encompass the full spectrum of symptoms and impairments presented by Terrance, which are specific to fetal alcohol syndrome.

3. A male patient calls to tell the nurse that his monthly lithium level is 1.7 mEq/L. Which nursing intervention will the nurse implement initially?

Correct answer: B

Rationale: A lithium level of 1.7 mEq/L is above the therapeutic range, indicating a potential risk of toxicity. The initial nursing intervention should be to instruct the patient to hold the next dose of medication and promptly contact the prescriber for further guidance and management. This action aims to prevent adverse effects and ensure the patient's safety by addressing the elevated lithium level appropriately.

4. Which of the following is not an effect of the drug isoflurane?

Correct answer: A

Rationale: Isoflurane is not known to cause elevated lipid levels. Common effects of isoflurane include nausea, increased blood flow to the brain, and decreased respiratory function. Elevated lipid levels are not typically associated with the administration of isoflurane, making choice A the correct answer.

5. While caring for a client receiving a blood transfusion who reports chills, which action should the nurse take first?

Correct answer: A

Rationale: The correct action for the nurse to take first when a client reports chills during a blood transfusion is to stop the transfusion. Chills can indicate a transfusion reaction, which is a potentially serious situation. Stopping the transfusion immediately is crucial to prevent further complications. Administering acetaminophen or checking the client's blood pressure can come after ensuring the safety of the client by stopping the transfusion. Notifying the provider is important, but the immediate priority is to stop the transfusion.

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